Fragmented menopause and mental health care
Lack of joined-up care between menopause and mental health services, insufficient understanding, and inadequate national guidance.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
100match
#15 - Community Mental Health Services fragmentation persists, requiring sustained investment for integrated support models.
Community Mental Health Services (CMHS) are integral to supporting people with severe mental illness across health, social care, and with their wider social needs. Evidence to this inquiry shows that integrated models of support within multi-disciplinary teams—such as co-located teams and Individual Placement and Support—can improve outcomes and reduce system pressures. However, fragmentation across services persists. Without sustained...
Matched on
terms: care, health, mental
Committee recommendation
100match
#2 - Lack of continuity of care fragments support for people with severe mental illness
Continuity of care is a necessity for people with severe mental illness. It is essential to the delivery of high-quality care. When it is present, it prevents crisis, builds trust, and supports recovery. When it is absent, it fragments support, burdens families, and puts lives at risk. This continuity must be built into the design of mental health...
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terms: care, health, mental
HSSIB recommendation
100match
Care delivery within community mental health teams
HSIB recommends that the National Institute for Health and Care Excellence evaluates the available research relating to the risks associated with menopause on mental health and if appropriate, updates existing guidance.
Matched on
terms: care, health, menopause, mental
PFD report
99match
Philip Denning
The coroner identified fragmented service provision for patients with co-occurring substance misuse and mental health issues, with insufficient information sharing and joint working between providers. There is also a lack of understanding in primary care about accessing appropriate help.
Matched on
terms: care, fragmented, health, mental
Committee recommendation
99match
#9 - Fragmented mental health system requires sustained investment and cultural shift for transformative community care.
Delivering real change and achieving parity of esteem in mental health care requires dismantling the current fragmented system and reimagining service design and delivery. The 24/7 Neighbourhood Mental Health Centre 75 pilots seem to be genuinely transformative. The experience from Trieste, and early evidence from Barnsley Street, show that radically different, individualised, community-based care gets results. We also...
Matched on
terms: care, fragmented, health, mental
Committee recommendation
99match
#3 - Current mental health services fail to provide person-centred, holistic care
Service users, their families, carers and loved ones have been clear: high- quality care must be person-centred, responsive to the full range of needs individuals experience, and ensure involvement of their wider networks. Current services too often fall short—focusing narrowly on diagnosis, overlooking physical health, and failing to support people with housing, employment, and social connection. People are...
Matched on
terms: care, health, mental
Committee recommendation
99match
#4 - Perinatal mental health investment remains insufficient and geographically limited to address needs.
Perinatal mental health is as important as physical health, with poor mental health outcomes having potentially significant long-term consequences for both the mother and child. We were struck by how frequently mental health concerns were raised in evidence. Given that the Government’s 54 new investment is available only to the original 75 local authority areas this will struggle...
Matched on
terms: care, health, mental
PFD report
97match
Jude Lloyd
The coroner identified inadequate diabetes care planning and monitoring before discharge, alongside insufficient communication between inpatient, community mental health teams, and GPs. There was also a lack of formal mental capacity assessments and robust audit systems.
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terms: care, health, mental
Committee recommendation
95match
#5 - Set actions to improve perinatal mental health access within Family Hubs for ethnic minority women.
The Government should set out what actions it will take to improve access to perinatal mental health care within Family Hubs, supported by specific targets to improve access for women from ethnic minority backgrounds who have disproportionately poorer mental health outcomes. (Recommendation, Paragraph 33)
Matched on
terms: care, health, mental
Committee recommendation
94match
#49 - Prioritise mental health support for children in care and pilot co-located CAMHS services.
The Department for Education should work with the Department of Health and Social Care to ensure that children in care and care leavers are prioritised for mental health support and improve training for mental health practitioners on the impact of trauma. This could be achieved by setting up co-located mental health services between children’s social care and Child...
Matched on
terms: care, health, mental
PFD report
93match
Samiyo Farah
Concerns included the absence of national observation protocols for young people in mental health units and a lack of formal information transfer protocols between healthcare sectors. The coroner also noted inconsistent psychiatric referral decisions in A&E.
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terms: care, health, mental
PFD report
93match
Lee Swain
The coroner identified a lack of co-ordinated mental health service transfers between NHS Trusts, as removing a user from the Care Programme Approach led to GP-mediated referrals, delaying intervention and hindering information exchange.
Matched on
terms: care, health, mental
PFD report
93match
David Buttriss
The coroner identified communication gaps between GP and mental health services, disparate healthcare record systems hindering information sharing, and a lack of clarity regarding appropriate crisis pathways and team roles for patients in mental health crisis.
Matched on
terms: care, health, mental
PFD report
93match
Danyon Chesters
Delays in accessing NHS mental health services led the individual to private therapy, resulting in a lack of joined-up care and information sharing. Concerns were also raised that private therapists have no obligation to obtain information about medication prescribing.
Matched on
terms: care, health, mental
PFD report
93match
Fadhia Seguleh
There was insufficient information sharing and coordination between the NHS Mental Health Trust, GP, and private therapist, leading to an incomplete understanding of risks and treatment. Remote mental health assessments and unaccompanied A&E attendance due to COVID-19 also limited comprehensive care.
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terms: care, health, mental
Committee recommendation
91match
#21 - Commission women's health hubs to include mental health support in core specification in underserved areas
Women’s health hubs situated in areas where access to appropriate mental health services is lacking should be commissioned to include mental health support as part of their core specification.
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terms: health, mental
Committee recommendation
90match
#8 - Improve NHS website with interactive tools, guidelines, accessibility, and mental health support
To supplement improvements in the provision of information on the NHS website, we recommend the inclusion of an interactive tool which can help women to determine whether they might have a reproductive health condition. We further recommend that information on specific conditions, contains links to the relevant medical guidelines so that patients can make themselves aware of the...
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terms: care, health, mental
PPO recommendation
90match
The Heads of Healthcare at HMP Manchester and HMP Buckley Hall
The Heads of Healthcare at HMP Manchester and HMP Buckley Hall should ensure that: liaison between prisons takes place when prisoners with a history of severe and enduring mental illness are transferred to Manchester and that the outcome is fully documented in the prisoner’s medical records. All prisoners identified as requiring an urgent mental health assessment are assessed...
Matched on
terms: care, health, mental
PFD report
89match
Jennifer Lewis
The coroner raised concerns regarding the lack of consultation between mental health and physical health doctors, and the failure to provide suitable and adequate care for the patient's needs at the Centre.
Matched on
terms: care, health, mental
PFD report
89match
Alice Litman
The coroner identified gaps in the knowledge, training, and guidance for clinicians supporting transgender individuals in mental health and primary care. Concerns also include delays in accessing gender-affirming healthcare and a lack of mental health provision for those awaiting treatment.
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terms: care, health, mental
PFD report
89match
Shahzadi Khan
The coroner identified concerns regarding out-of-area mental health placements resulting from bed shortages, which impeded family contact and information sharing. Issues also included coordinating teams' insufficient understanding of local care pathways and effective discharge planning.
Matched on
terms: care, health, mental
PFD report
87match
Conrad Colson
The coroner identified insufficient liaison and information sharing between specialist and step-down mental health services for a BDD patient on discharge. Concerns included a lack of risk communication regarding aesthetic treatments for BDD, and limited national resources and training.
Matched on
terms: health, mental
Committee recommendation
87match
#20 - Offer specialist mental health support to individuals with reproductive health conditions from first symptoms through treatment
Individuals with a suspected or diagnosed reproductive health condition should be offered specialist mental health support from when they start to report distressing and/or painful symptoms and throughout diagnosis and treatment. Delays at each step of the process and a lack of treatment options make mental health support all the more essential.
Matched on
terms: health, mental
PPO recommendation
86match
The Head of Healthcare
The Head of Healthcare should conduct an urgent review of the following areas of mental healthcare delivery at Wakefield: ▪ develop a protocol for disseminating transfer handover information, within a centralised email system, not to an individual staff member’s email, to minimise the loss of critical clinical information; ▪ ensure all staff within the mental health team understand...
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terms: care, health, mental
PFD report
85match
Matthew Dunham
The coroner noted delays in acting on an emergency mental health referral and a lack of clear understanding of appropriate team roles. Concerns also included insufficient action on specific suicidal ideation and poor information sharing between mental health professionals.
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terms: health, mental
PFD report
85match
Janet Blackman
The coroner noted psychiatric units struggle to provide physical health care and that deep vein thrombosis (DVT) prophylaxis policies were not consistently applied to patients in these units. The report suggests developing a system for integrated physical and mental health care delivery.
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terms: care, health, mental
PFD report
85match
Elizabeth Godwin
The coroner identified concerns regarding the process for gathering information for mental health assessments, assessing their urgency, and sharing this information with other agencies. Further concerns relate to establishing responsibility for patient care and ensuring clear communication during transfers between agencies.
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terms: care, health, mental
PFD report
85match
Charlotte Bevan and Zaani Malbrouck
The coroner noted a lack of evidence that multi-disciplinary team meetings are consistently held or that comprehensive, widely-circulated care plans are consistently developed for pregnant individuals with known mental health conditions.
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terms: care, health, mental
PFD report
85match
Jonathan Zucker
The coroner identified the absence of a requirement or system for a lead clinician to oversee and coordinate Mr. Zucker's care, which was provided by both private and NHS mental health services.
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terms: care, health, mental
PFD report
85match
Margaret Conway
The coroner notes that Acute Medical Wards and Mental Health Services are geographically and operationally separate, making transfers of patients with co-occurring serious mental and physical health problems challenging. Improved integrated working, clear pathways, and shared resources are needed to enhance care.
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terms: care, health, mental
PFD report
85match
Darren Lawrence
Inadequate communication and transfer processes between mental health teams and general practitioners led to insufficient follow-up and unprescribed medication. Concerns also included a lack of escalation protocols for patient disengagement and gaps in medication monitoring.
Matched on
terms: health, mental
PFD report
85match
Gaia Pope-Sutherland
The coroner identified a lack of communication between community psychiatric and neurology teams across England and Wales, alongside under-resourced epilepsy services, particularly insufficient nursing staff. The report also noted a need for improved police training on epilepsy and complex mental health conditions when dealing with missing persons.
Matched on
terms: health, mental
PFD report
85match
Donna Donnellan
The coroner identified a lack of understanding between Acute and Mental Health Trust clinicians regarding the specific role of the Mental Health Liaison Team for eating disorder patients. There was also a lack of clarity on referral pathways to specialist eating disorder services.
Matched on
terms: health, mental
PFD report
85match
Angela Collins
Vulnerable adults under the care of secondary mental health services by East London NHS Foundation Trust receive very limited or no support despite being at risk of prescription drug overdose or mental health crisis.
Matched on
terms: care, health, mental
PFD report
85match
Kirsty Taylor
The coroner identifies insufficient connectivity between mental and physical health services, particularly for neurodivergent patients, and notes a lack of a comorbidity policy. Further concerns include the pace of developing a personality disorder pathway and ineffective communication with families of mental health patients.
Matched on
terms: health, mental
PFD report
85match
Amarnih Lewis-Daniel
The coroner raised concerns about extensive waiting lists for Gender Identity Disorder clinics, insufficient local patient support, and unclear responsibility for wellbeing during this period. There was also a noted lack of specialist knowledge in local mental health services and clear guidance for GPs on bridging hormone prescriptions.
Matched on
terms: health, mental
PPO recommendation
85match
The Head of Healthcare, the lead GP and the lead manager of the mental health service
The Head of Healthcare, the lead GP and the lead manager of the mental health service should: • review the system for the follow up of patients who do not meet the threshold for input from the mental health team but who continue to be referred; and • clarify the GP role and the development of shared care...
Matched on
terms: care, health, mental
Committee recommendation
85match
#46 - NHS England needs national menopause strategy to retain senior staff
NHS England should develop and implement a national menopause strategy focused on the retention of senior staff who may be reducing their hours, leaving management or supervisory roles, or retiring earlier than intended, because of a lack of support around menopause.
Matched on
terms: care, health, menopause
PFD report
81match
Stephen Morris
The coroner noted a limited exchange of mental health information between professionals in Cheshire and Blackpool, meaning Blackpool staff lacked a detailed understanding of the patient's recent presentation and risks upon his return.
Matched on
terms: health, mental
PFD report
81match
Nancy Hughes
The coroner identified a lack of medication reviews in accordance with accepted practice and no system to ensure them. There was also insufficient cohesion between mental health and medical treatment, which meant staff lacked access to mental health information for vulnerable patients.
Matched on
terms: health, mental
PFD report
81match
Samantha Gould
The coroner raises concerns about the lack of national guidance for pharmacies to be involved in medication safety plans for mental health patients aged 16-17, noting this poses a risk of future fatalities.
Matched on
terms: health, mental
PFD report
81match
Gareth Williams
The coroner noted insufficient support for the individual, who was transferred between mental health and ENT teams that did not communicate directly, resulting in them falling between services.
Matched on
terms: health, mental
PFD report
81match
Samuel Morgan
The coroner raises concerns about the lack of integrated electronic records between alcohol and drug addiction services and primary community mental health teams. This hinders effective sharing of patient safety information, particularly for dual diagnosis cases, increasing the risk of important details being lost.
Matched on
terms: health, mental
PFD report
81match
Corinne Haslam
Concerns were raised regarding barriers for mental health staff to access physical health specialists without emergency department use, incompatible electronic record systems hindering information transfer between trusts, and insufficient guidance for nursing staff on Venous Thromboembolism risk assessments.
Matched on
terms: health, mental
PFD report
81match
Jason Pulman
The coroner raises concerns about a lack of clarity for CAMHS teams, patients, and parents regarding national referral mechanisms for gender services and the resources available to provide mental health support for young people on waiting lists. This situation may lead to extended wait times and potential risks while awaiting treatment.
Matched on
terms: health, mental
PFD report
81match
Evie Davies
The coroner noted a lack of real-time information sharing between the cafe71 service and the mental health team, meaning cafe71 staff lack access to patient background and risk factors, and mental health teams are not notified of contacts.
Matched on
terms: health, mental
PFD report
77match
Gillian Taylor
The coroner identified the absence of an acute mental health facility in Powys, leading to patients being moved long distances and a resulting lack of continuity of treatment. This situation may negatively impact patient engagement with mental health services.
Matched on
terms: health, mental
PFD report
77match
David Price
The coroner noted a lack of an integrated mental health counselling and detoxification service in Stockport, which would enable joint treatment for co-occurring alcohol dependency and anxiety.
Matched on
terms: health, mental
PFD report
77match
Marlene McCabe
The coroner identified potential for a lack of understanding among clinicians regarding urgent mental health referrals, and inconsistent access to mental health records hindering information sharing. Concerns were also raised that drug/alcohol references or perceived intoxication could lead to missed mental health diagnoses or delayed identification of psychosis.
Matched on
terms: health, mental
Committee recommendation
77match
#4 - Ensure all FGM survivors access timely, essential support and specialist care nationwide
The Government should ensure that all FGM survivors can access the essential support and care they need in a timely manner. While some variation in service provision may be necessary to reflect local prevalence rates, higher-prevalence areas should offer funded multidisciplinary services that allow quick access to specialist care. In lower-prevalence areas, there must be clear referral pathways...
Matched on
terms: care, health